The rugged topography of the Appalachian Mountains geographically delineates the diverse region known as Appalachia. Most counties within Appalachia are designated as medically underserved, have sparse health care resources and lack integrated care systems, though a few highly urbanized, more prosperous areas found within or near the borders of Appalachia. We believe that a general lack of proximity to comprehensive medical services is associated with the recently reported excess cancer incidence and mortality in Appalachia, though no studies have systematically examined cancer treatment patterns, such as underuse of therapies and gaps in care. This three-year study will document and describe patterns of care for female breast and colorectal cancers diagnosed in 2006-2008 from state cancer registry, census and Medicare claims data files for a large region of Appalachia. The study population will include all estimated (N=7,800) cases of female breast cancer and (N=8,700) cases of colorectal cancer cases in among residents of Appalachian counties of PA, OH, KY, and NC. Study data will be processed, supplemented and quality assured necessary to determine the proportion of cases receiving National Comprehensive Cancer Network (NCCN) guideline concordant care for breast and colorectal cancer. These results will be compared to estimated rates of breast and colorectal cancer care for the study states, separately and pooled. Regression analyses of Appalachia data will seek to identify patient, tumor, provider, and facility factors that contribute to significant variation in receipt of the guideline-concordant care for breast and colorectal cancers including: 1) Age, race, gender (colorectal cancer only), comorbidity status, and socioeconomic status as proxied by dual enrollment in Medicaid and the socioeconomic status of patient's census tract of residence, 2) Facility typology and provider characteristics; and 3) Travel time distance from patients residence to specific types of providers (e.g., high volume of cancer care, comprehensive treatment center and oncologist practice). The effects of differential distance to specific types of providers (e.g., high volume of cancer care, comprehensive cancer services) will be modeled as an instrumental variable that corrects for selective referral. Secondary aims include exploring patient, facility and provider characteristics associated with delays in treatment and access to new or leading therapies. Study findings will be disseminated to Appalachian communities, policy makers, health care providers and to the scientific community. PUBLIC HEALTH RELEVANCE: This study seeks to identify patient, tumor, provider, and facility factors that contribute to significant variation in receipt of the guideline-concordant care for approximately 15,000 breast and colorectal cancers in a large region of Appalachia. Study aims will focus on the contributions of : i) Age, race, gender (colorectal cancer only), comorbidity status, and socioeconomic status (ii) Travel time distance from patients residence to specific types of providers (e.g., high volume of cancer care, comprehensive treatment center and oncologist practice); and (iii) Facility volume, type, comprehensiveness and accredited status, and surgeon case volume, training status, and vintage.